EHR Selection Preparedness: Data Management
In the third of our readiness assessments or “environmental scans,” evaluate what kind of data you collect, how data are gathered, and where it is stored. Old paper storage habits (a file here, another there) can easily translate into a messy and over-loaded server as well.
Start by knowing what data is collected? A typical list of health information in a medical record includes the following.
» H & P’s
» Medication lists
» Encounter Notes
» Procedure reports
» Pathology reports
» Other labs reports
» Imaging results/reports
» Treatment Plans
» Diagnosis based documentation and treatment templates
» External Care (notes, reports, inpatient care)
» Demographics Sheet
» Insurance information
» Driver’s license
» Consent and authorization forms
» Emergency contacts
You are going to love how the EHR organizes all of these content fields for you. All of these content areas are housed in data fields so they are searchable. In EHR training, you learn how to put the right information in the right place so that the right person can access it at the right time. All of us develop storage habits while functioning in the paper world – most of them we don’t want to carry over into the EHR. In a data management assessment, look for the following:
How often does the same lab result get filed into the patient record?
How many times do you duplicate a patient record when you can’t find the original? And do you know which file is the original?
How often does health information get filed into the wrong folder?
As paper comes in to the practice, is it stored chronologically, or is it indexed?
The next assessment area is to know how you document the encounter.
How Do You Collect Data?
Paper records have been both a point of contention (Who has Mrs. Jones’ file?) as well as a comfort zone for physicians who are accustomed to writing. The traditional pen and paper process of capturing clinical notes does not have to be a major challenge for the staff and physicians during the transition.
Start by making a list of how your providers prefer to create content. Most likely this includes handwritten notes, typing, and dictation.
In an EHR, clinical information still goes into the medical record, but it now is captured electronically in one or more of the following ways:
» Point and click templates using drop down menus
» Free text (typing)
» Handwriting recognition (using a stylus)
» Medical imaging and graphics (drawings built in the software for markup with a stylus)
» Speech recognition using software
» Digital voice dictation using a transcriptionist
The physician leadership may say, “we’re all going to learn to type,” but to the typical visual learner, that means hunt and peck – head down focused on the keyboard rather than maintaining eye contact with the patient – lost productivity. Instead, start with where you are. For clinicians who want to continue dictation, consider voice recognition software or electronic dictation. Physicians who want to keep writing can learn how to use a stylus instead of a pen. Other physicians type the encounter into the EHR outside the exam room where you also may be generating lab orders and writing prescriptions.
Point and click and/or drop down templates and free text are standard in all EHRs, but handwriting, speech recognition and digital dictation require additional licensing fees for the software, well worth the cost to maintain the clinician’s productivity.